Week 8: Spinal Cord Lesions Flashcards
The mature spinal cord ends at what vertebral level?
How long is it?
How many segments does it have?
Spinal cord level- what corresponding vertebral body is at same height? Upper cervical Lower cervical Upper thoracic Lower thoracic Lumbar Sacral
Ends about L1
46cm long
31 segments
Corresponding Vertebral level: Upper cervical- same as cord level Lower cervical- 1 level higher Upper thoracic - 2 levels hi her Lower thoracic- 2-3 levels higher Lumbar - T10-T12 Sacral T12-L1
Determining the level of the lesion: Each result in: Cervical cord lesion: Horners syndrome (miosis, ptosis and facial hypohidrosis) can occur at any level -upper cervical cord lesion C4-C5 C5-C6 C7 C8
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The presence of a horizontally defined level below which sensory, motor and autonomic function is impaired is a hall mark sign of spinal cord disease.
The level is determined by using the pin prick to map out the level.
• Sensory loss below this level is the result of damage to the spinothalamic tract on the opposite side, one to two segments higher in the case of a unilateral lesion or at the level for a bilateral lesion.
Cervical cord lesions
• Horner’s syndrome (miosis, ptsosis facial hypohidrosis)can occur at any level
• Upper Cervical Cord lesion o Quadriplegia
o Weakness of the diaphragm
• C4-5
o Quadripelgia
• C5-6
o Loss of power and reflexes in the biceps
• C7
o Weakness of the triceps, finger and wrist extensors • C8
o Weakness of the finger and wrist flexion
Determining level of lesion:
Thoracic cord lesions:
how are they localised?
Thoracic cord lesions
• Localised by the sensory level on the trunk and the site of midline back pain (if it is present)
• Nipples = T4
• Umbilicus = T10
• Leg weakness and disturbances of bladder and bowel function accompany the paralysis
• T9-10
o Paralyse the lower but not upper abdominal muscles
Lumbar cord lesions:
L2-L4
L5-S1
L2-L4
o Paralyse flexion and adduction of the thigh o Weaken knee extension
o Diminish the patellar reflex
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L5-S1
Paralyse movements of the foot and ankle o Weaken hip extension
o DiminishtheAchillesreflex
Sacral Cord Lesions
o Sacral cord lesions
• Conus medullaris
o Bilateralsaddleanaesthesia(S2-S5)
o Prominent bladder and bowel dysfunction and impotence o Diminishthebulbocavernosisandanalreflexes
• Cauda Equina (see video clip) o Low back pain
o Radicularpain
o Asymmetric leg pain, weakness and sensory loss
• Mass lesions in the lower spinal canal result in a mixed clinical picture of both conus medalluris and cauda equina
Special patterns of spinal cord lesions: Brown- Sequard hemicord Syndrome what is it? If there was corticospinal tract damage what would happen? If there was dorsal column? Spinothalmic?
If Corticospinal tract damage
• Ipsilateral UMN below level of the lesion thus spastic leg
• Increased reflexes in lower limb
• Extensor plantar response
Dorsal column below the level of lesion
• Ipsilateral loss of proprioception, light touch and vibration Spinothalamic tract findings –
• Contralateral loss of pain and temperature
• Segmental signs are unilateral and ipsilateral
o Radicular pain
o Muscle atrophy, flacid paralyis o Loss of DTR
If above the level of T1 then Horners syndrome due to damage of sympathetic ganglion
Special patterns of spinal cord lesions:
Anterior spinal artery Syndrome
Most common cause of spinal cord infarction
• Anterior spinal artery covers anterior 2/3 of the cord
• Posterior columns spared – proprioception, vibration & touch
• All spinal cord functions below the level of the lesion are lost
o Motor, sensory and autonomic
o Vibration and proprioception spared.
Special patterns of spinal cord lesions:
Central cord syndrome
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• Most commonly caused by spinal trauma particularly hyperextension
in elderly, syringomyelia and intrinsic cord tumours.
• Pain in the upper limbs is often an early sign & more severe than lower
• Unilateral or bilateral Horner’s syndrome
• Wasting of the small muscles of the hand
• Arm weakness out of proportion to leg weakness
• Dissociated sensory loss (loss of pain and temp but not vibration, light touch and proprioception) in a cape distribution
Neoplastic Spinal cord compression:
Most common tumours to metastasise to spine are:
Symptoms?
Neoplastic spinal cord compression
• Most common tumours to metastasize to the spine are
o Breast
o Lung
o Prostate
o Kidney
o Lymphoma
• The thoracic area is the most common area for metastasis
• Pain is usually the initial symptom
o Aching and localised or sharp and radiating
o Worsens with movement, coughing, sneezing
• Neurological symptoms depend on where the tumour is pressing
Spinal epidural abscess:
what is it?
Presents with what?
Risk factors?
A spinal epidural abscess is an accumulation of pus in the epidural space that can mechanically compress the spinal cord. Spinal epidural abscesses usually occur in the thoracic or lumbar regions.)
pinal epidural abscess • Presents with the following triad o Midlinedorsalpain o Fever o Progressivelimbweakness • Aching pain is almost always present either over the spine or in a radicular pattern • Risk factors include o Impairedimmunestatus • Diabetes • Renal failure • Alcoholism • Malignancy o IVdruguse o Infections • 2/3 occur from infections of the skin
Spondylitic Myelopathy
What is it?
What will you see?
refers to impaired function of the spinal cord caused by degenerative changes of the discs and facet joints in the cervical spine (neck))
One of the most common causes of chronic cord compression and
gait difficulty in the elderly
• Neck and shoulder pain with stiffness are the early signs!
• Impingement of bone and soft tissues causes radicular pain
• Cervical compression (1/3)
o Slowly progressive spastic paraparesis
o Vibratory sense is diminished in the legs
o Romberg’s sign
o Dermatomal sensory loss in the arms – buttons, writing
o Atrophy of the intrinsic hand muscles
o Increased DTR in the legs and biceps (depends on where the lesion is)
o Extensor plantar response
Subacute Combined Degeneration of the cord (SCDC)
What is it?
Whats symptoms and signs?
refers to degeneration of the posterior and lateral columns of the spinal cord as a result of vitamin B12 deficiency, copper deficiency or vitamin E deficiency. It is usually associated with pernicious anemia.
AKA Vitamin B12 deficiency - reversible
• Subacute paraesthesias in the hands and feet
• Loss of vibration and position sense
• A progressive spastic and ataxic weakness
• Loss of reflexes due to a peripheral neuropathy in a patient who has
a Babinski sign is an important diagnostic clue
• Signs are generally symmetric
• Romberg’s sign
Multiple Sclerosis
Characterised by?
tell me some stuff about it.
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Multiple sclerosis (MS)
• Is a chronic disease which is characterised by;
o Inflammation
o Demyelination o Gliosis (scarring) o Neuronal loss
• The course can be relapsing-remitting or progressive
• Different parts of the cord are affected each time (90% of cases)
• MS is approximately 3 times more common in women than men
• The age of onset is typically 20-40 years of age / less # with sunlight
• The onset of MS may be abrupt or insidious
• Symptoms may be severe or minor so that the patient is not even aware of them.
• Symptoms are often aggravated by heat
Environmental influence:
-northern hemisphere signify more likely to get MS
meh
What are the initial symptoms of MS?
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-sensory loss optic neuritis Weakness (UMN) Paresthesiaas Diplopia Ataxia Vertigo Paroxymal attacks (spasm, seizure) -bladder (>90%) -pain
MS
Examination often reveals?
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Symptoms:
o Neurological dysfunction often in asymptomatic areas
o Weakness of the limbs
• Loss of strength, speed or dexterity
• Fatigue
• Disturbance of gait
o Spasticity
• Is often associated with spontaneous and movement induced
muscle spasms
• 30% of cases have moderate to severe spasticity especially in the legs
o Opticneuritis
• Presents as diminished;
o Visualacuity
o Dimness
o Decreased colour perception in the central field of vision
o Sensory symptoms • Varied
o Paraesthesias – abnormal tingling, tickling, burning o Hypaesthesia – diminished sensitivity to stimulation o Unpleasant sensations
o Pain is common
• It can occur anywhere in the body
• Changes locations over time
o Ataxia
• Usually manifests as cerebellar tremors (intention tremors)
• Can also involve the head and trunk or the voice – scanning speech
o Bladderdysfunction • Present in more than 90% of cases • 1/3 of patients have weekly or more frequent episodes of incontinence o Constipation • Occurs in more than 30% of cases o Cognitivedysfunction • Can include o Memory loss o Impairedattention o Slowedinformationprocessing o Difficultiesin • Executive functioning • Memory • Problem solving • Moving between cognitive tasks
o Depression • Experienced in 50% of patients • Is it a symptom or a result? o Fatigue • Experienced in 90% of patients o Sexual dysfunction • Decreased libido • Impaired genital sensation • Impotence in men • Diminished vaginal lubrication
